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ENESM ��E�rr�w ��rr�� ,�■�� E� asp■■ .E�rir��rrr�r�� ■��■ i�■��rr��r��rri .�■��MONNE MINEW EMEM ME WOMME ma ME clucalmCal r ¢�tiN�f p�, o o � d �lassackttsctts` DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKEIVSS COMPENSATION INSURANCE AFFIDAVIT (licensee/permittee) with a principal place of business/residence at: 0/O � -iA IVj l M \ (phone#) Z3 7 2-� (strcet/city/stafr/ap) do hereby certify, under the pains and penalties of pemiry, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: 4 Ck 0 1/ (Insurance Company) (Policy Number) iratio Daze) am a sole proprietor, eneral contractor or homeowner (circle one) and have hired e ow who have the following worker's compensation policies: AMdl -TS-00o0,;L571 --?, 3k,-z (Name of Contractor) (Insurance Company/Policy Number) (Ehirati Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiradon Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additionsl shove if necessary to include information pertaining to an matradors) (vr I am a sole proprietor and have no one working for me. ( ) I am a home owner performing aLL the work myself. NOTE-please be aware that while homeowncn who employ pcuons to do ms;,.r__ to__.a r o=st1xdon or repair work on a dwelling of not more thaw throe units in which the bomeowner raider or on the grounds apputtenmrt shade an not Sena% y considered to be employers under the wod=As oompeasatioa Ace(GL I52,ss 1(5)),application by a homeowner for a Hoam or permit may evidence the legsl statue of an employer under tha Worker's Compeosation Act. I understand that a copy of this slat—of may be f%vmzded to tha Departnxnt of Industrial A=den Offioe of ln%xanoe for the ooverxge verification and that failure to securt covecago undw soctioa 25A of MGL 152 can lead to the imposition of Criminal penalties Consisting of a fine of up to 51,500.00 and/or imprison of up to Coe ytw and civil penalties in the form of a stop Work order and a find of 5100.00 a day agaiasi t= For tnocotnl use caly Number ! a ______: Lot# SiVmKe of Licensee/Permittee SECTIONS CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ I �( Name of License Holder C—)6, O 6' License Number Address V Expirati Date �nre Telephone Not Applicable ❑ EtE Company Name Registration Number Address Expirati n Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, §25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780 Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5 DE$!9flJPTION OE PROPOSED WQ8K(0#ck all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: '�F1 wvr r- E AQt lily- wmlow , C f r Pxlt '17i ��R F15CQ01Z1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �!G� -�I"� • �[.- as Owner of the subject property hereby authorize k to act on my behalf, in all mat rs relativ ork authorized by this building permit application. O �01 _P_ U/ Signat o Owner Date I , as Own%Cuthorized�Agent hereby declare that he t statements and information on the foregoing application are true and accurate, knowledge and belief. Signed under the pains and penalties of perjury. Print Name l Z/2>Z& Signature of Owner/A& Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO �� DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property?YES No IF YES, describe size, type and location: U VV V City of Northampton Building Department 212 Main Street Room 100 DEPT Of BUILDING INSPECTIONS Northampton, MA 01060 N0 R T l •, Tfk 14 NS',0?C%ri plione-413-587.1240 Fax 413-587.1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 '-SITE INFORMATION This s cti ae cotn I yfi 1.1 Property Address: sr Zolne frerlapl�rict oVZ Elva St.`blsfrlct SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: -5 79: U d lvl,i, (—t Na t) Current Mailing Address: I Telephone Signature 2.2 Authorized A ent Name(Print) Current Mailing Address: 20 Signatv1d, Telephone SECTION 3' ESTIMATED.CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building -S-00 0 0 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee' 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5) f,1 00. iCheckNumber This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings - Date File#BP-2001-0477 APPLICANT/CONTACT PERSON Mark Bibeau ADDRESS/PHONE 71 NORTHAMPTON ST (413)527-5827 PROPERTY LOCATION 218 BRIDGE ST MAP 25C PARCEL 122 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out 42.14 1.01 Fee Paid Tvpeof Construction: REPLACE EXISTING WINDOW WITH DOOR TO FIRE ESCAPE New Construction Non Structural interior renovations Addition to Existing_,_ Accessory Structure Building Plans Included: Owner/Statement or License 068684 3 sets of Plans/Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § —w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § —w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commissi Permit from CB Architecture C ee f Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. r 218 BRIDGE ST BP-2001-0477 GIs#: COMMONWEALTH OF MASSACHUSETTS Map Block:25C- 122 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0477 Proiect# JS-2001-0813 Est.Cost:$1500.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin Mark Bibeau 068684 Lot Size(sq.ft.): 3615.48 Owner. FOGEL BRUCE M&PAULINE G Zoning.URB Applicant. Mark Bibeau AT. 218 BRIDGE ST Applicant Address: Phone: Insurance: 71 NORTHAMPTON ST (413) 527-5827 EASTHAMPTONMA01027 ISSUED ON.1118100 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING WINDOW WITH DOOR TO FIRE ESCAPE POST THIS CARD SO IT IS VISIBLE FROM THE STREET nspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: wilding 11/8/00 0:00:00 1590 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo fi=r ,`� z ..k. F ±.' l Sr 3t .,r('...Y "S woy k ,xt.,,,.: r µ t dAymp am Tom YN PER", WK a to s , ; �✓ c f 5, , ( a f ic y t , .Ip`S d t j qq l WWI naby", n,$ vX fy tf �, 218 BRIDGE ST BP-2001-0477 GIs#: COMMONWEALTH OF MASSACHUSETTS Mai:Block:25C- 122 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0477 Project# JS-2001-0813 Est.Cost:$1500.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Mark Bibeau 068684 Lot Sizes%Q: 3615.48 Owner: FOGEL BRUCE M&PAULINE G zoning URB A_MUcant. Mark Bibeau AT: 218 BRIDGE ST _ AnnlicantAddress. Phone: Insurance: 71 NORTHAMPTON ST (413) 527-5827 EASTHAMPTONMA01027 ISSUED ON:1118100 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING WINDOW WITH DOOR TO FIRE ESCAPE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: i1: Insulation: Final: Smoke: Final: Q if /�—t;,QQ THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy si nature: Fee Tvae: Receipt No: Date Paid: Check No: Amount: Building 11/8/000:00:00 1590 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo